DOUBLE TROUBLE

Leo Turok hears voices. It started when he was 16 and studying at Lord Byng
Elementary. Soon, the paranoia began keeping him in his room at home and
away from friends at school.

He quit school before graduating. Every six months or so, when the suicidal
urges became too great, he'd admit himself into UBC's emergency ward. He
would return to normal quickly, so it wasn't until he was 19 that Turok was
diagnosed as schizophrenic. He spent three months at UBC's psychiatric ward
stabilizing and adjusting to his new drug regime. After leaving the
hospital, Turok went to a Mental Health Services support home in Kitsilano
where he lasted all of three weeks before being forced out for anti-social
behavior.

A friend offered to move into a West End apartment with Turok, but again,
anti-social behaviour-mostly paranoia that friends were trying to harm
him-drove his friend away. Turok moved into a bachelor suite, still in the
West End, and started dabbling in street drugs. The apartment soon became a
flophouse for homeless drug users he met on Davie Street and the Downtown
Eastside.

Turok was registered with the West End Mental Health Clinic and was still
showing up for his biweekly medication injection when he began taking more
street drugs, mostly speed and crack. A clinic street nurse noticed the
pattern and told Turok's mom Olga.

No one was sure what to do about it.

Soon Turok stopped going to the clinic. When he couldn't pay his rent, he
moved briefly back to his Vancouver home, where he would demand to be
locked in his room so no one could harm him. Olga took her son back to UBC
hospital. From there, he was sent to Riverview Mental Hospital, where he
stayed 13 months before being refused service for repeatedly escaping and
using drugs.

From Riverview, Turok had nowhere to go but the Downtown Eastside, to the
city's three homeless shelters-The Lookout Emergency Aid Society, 346
Alexander St.; Triage Emergency Services and Care Society, 707 Powell St.;
and The Haven, 128 East Cordova St.-where his drug use worsened and the
voices in his head increased. Now, when 24-year-old Turok calls his mom,
it's to arrange a quick meeting at McDonald's, where she brings him fresh
clothes that he changes into in the washroom.

"We went to McDonald's last Sunday," said Olga, her eyes tired,
semi-circular rings of worry permanently etched below them. "He looked
rundown and as usual, he just stared, but I took him shopping so he could
be around me. I'm not sure where he's living."

Turok is one of an estimated 34,000 British Columbians with "dual
diagnosis"-a mental health problem coupled with an addiction. Dual
diagnosis patients, many of whom live in the Downtown Eastside, represent
about half the total number of people suffering a serious mental health
disorder province-wide.

Despite the large and growing numbers, there are only six long-term care
beds specifically set aside for those with a dual diagnosis in Vancouver,
all of them in a support home in the Downtown Eastside that opened three
years ago as a pilot project. The average stay in the six beds available to
dual diagnosis sufferers is between six to 18 months, but turnover is high
because of behavior problems.

Advocates for such patients complain there's little co-operation or
cross-training between mental health and addiction services-addiction
workers are not trained to deal with mental illness and mental health
workers don't know how to deal with addiction.

The solution, say parents like Olga, is more money and service
co-ordination to save their sons and daughters from themselves.

On Powell Street, a block east of Oppenheimer Park, there's a nondescript
two-storey white building owned by The Lookout Society that houses a string
of social services. A beggar sits on the ground in front of the building, a
metre from the doorway, perhaps targeting the many professional health care
workers based in the Downtown Eastside.

Inside the building is the Vancouver Coastal Health Authority's Dual
Diagnosis Program. You need to climb two grubby flights of stairs before a
purple photocopied sheet of paper taped to the wall tells you the program
is located at the end of the hall to the right. The door is locked, and you
have to speak through an intercom system on the wall to get in.

Launched in 1996, the Dual Diagnosis Program treated 800 people last year
and survives on $500,000 a year, with four full-time staff and one
part-timer. Clients are referred from hospitals, detox centres, mental
health teams, residential treatment centres, GPs, psychiatrists and word of
mouth.

Treatment lasts between six to 18 months and helps clients identify when
they're "crashing" or spiralling downward through depression, paranoia,
substance abuse and other problems. Staff work with clients, most of whom
have mood disorders like manic depression and anxiety, post-traumatic
stress disorder or personality disorders, on preventing relapses and
dealing with conflict in their interpersonal relationships, including
managing their anger.

Alcohol is the most common addiction, followed by heroin and crack,
although most use a variety of drugs.

Coordinator Pohsuan Zaide says the dual diagnosis team's task is
enormous-the wait to get in is between six and eight weeks. "I could have
10 staff and we'd all still be busy. But this is what I have to work with
and I'll do what I can. No one's looking to do miracles; we just try for
some positive outcomes for patients. If we can give people hope and give
them back some self esteem and pride, then we've succeeded."

Determining whether the addiction or mental illness came first is often a
"chicken and egg" issue, she said. "If you've been using alcohol and drugs
for 25 years, you'll likely develop depression or an anxiety disorder. Or
if you have a mental illness you are easily abused and introduced to drugs,
especially here [in the Downtown Eastside]."

The concept of dual diagnosis emerged in 1986 when an acronym-PISA or
psychiatric impaired substance abusers-was coined to describe an addiction
co-existing with either a personality disorder, chronic mental illness or
post-traumatic stress disorder. The usual treatment was to determine which
of the two was the "primary" disorder, then focus on one.

But Ken Minkoff, a Massachusetts-based psychologist, advocated a new
approach: treating both disorders simultaneously, then finding out how the
two are related for each individual and getting that person to help devise
a recovery program.

Minkoff's work spawned the creation of programs like Vancouver's dual
diagnosis program, but most sufferers still fall through the divide between
mental health and addiction services, often because of multiple relapses.

"The problem is there's no consensus between the two systems. The mental
health people say go away and quit your addiction and then we'll treat you.
Or the addiction people say we can't treat you when you're on psychiatric
meds," said Zaide, who holds a master's degree in counselling

psychology from UBC. "You just can't operate separately any more or pass
the buck. They end up costing the health care systems more anyway, because
they keep using the emergency rooms and psych ward beds and are likely to
try suicide."

Zaide advocates better funding and licensing for recovery houses for
addicts, with better-qualified staff to deal with dual diagnosis.
Currently, anyone can establish an addiction recovery house, usually based
on the Alcoholic Anonymous 12-step program. Residents who also have a
mental health problem, however, are often asked to leave because of their
behaviour, which is not recognized by untrained staff as being driven by
mental illness.

Last month, the office of the Mental Health Advocate of British Columbia
was closed as part of provincial government cutbacks. Responsibility for
listening to the concerns of the mentally ill was passed on to Gulzar
Cheema, Minister of State for Mental Health and MLA for Surrey-Panorama Ridge.

The day Mental Health Advocate Nancy Hall left her job, she released a
stinging report on the state of the province's mental health system,
focusing on statistics showing a significantly increased risk of premature
death among those with a psychiatric diagnosis, likely from suicide or
conditions that stem from addictions.

One of her recommendations was for an assistant deputy minister to focus
solely on mental health and addiction issues.

"We need to provide training to community mental health teams, hospitals,
Riverview Hospital, forensic and physicians to ensure patients receive
concurrent help for the two disabilities," wrote Hall. "Few people with
both an addiction and mental illness get effective treatment for either
problem. People with dual diagnosis and their family members report
difficulty in getting help.

"Even when they are long-stay patients at Riverview Hospital or the
Forensic Psychiatric Hospital, there is no routine care provided for their
addictions."

One Vancouver mom, Heidi Richards, has filed a complaint with the B.C.
Human Rights Commission claiming the Vancouver/Richmond Health Board-now
the Vancouver Coastal Health Authority-discriminated against her son Adrian
by not treating his drug problem while he was receiving mental health care,
and not providing suitable housing options. Adrian was a former Riverview
patient who has schizophrenia and is now a drug addict, living at Triage in
the Downtown Eastside. He developed his addiction after being forced out of
support homes due to his behaviour and ultimately ended up on the Downtown
Eastside, where drug dealers target newcomers.

Roderick Louis, a former Riverview patient who has become a patient
advocate, said when he visits the Downtown Eastside, he usually sees at
least a dozen former Riverview patients wandering the area. Most are drug
addicts. Some are prostitutes.

"A lot of them have grown up in a decent neighbourhood and developed
schizophrenia, been stabilized and then discharged without support and
funneled right downtown to the only emergency shelters in B.C.," said
Louis, brother of Vancouver city councillor Tim Louis and founder of the
Patient Empowerment Society, which pushed for patients' rights at
Riverview. "They run out of money and quickly learn to make money either by
selling drugs or their body. They are right smack in the middle of the
biggest prostitution and drug addiction university in the province. It's
ghettoizing the mentally ill."

Louis believes providing the mentally ill with rent subsidies would go a
long way toward getting them out of the Downtown Eastside and away from the
drug culture.

But Zaide says centralizing mental health and addiction services in the
Downtown Eastside is not necessarily bad for clients. "Some clients say
where we are located is a good reminder of where they've been and where
they don't want to be. Some people's addictions get triggered, but you can
get drugs anywhere. You have to take responsibility for your recovery and
stop blaming others.

"Sometimes, there's not much you can do if someone is an adult and
adamantly refuses to get help."

The Patient Empowerment Society has met with Cheema to suggest he form a
multi-ministry mental health group to co-ordinate mental health, addiction,
housing and other government services used by the mentally ill. "You just
need someone with gumption in the premier's office saying let's link these
things up," said Louis, who, along with other advocates, is calling for
better funding and staffing for treatment and recovery facilities for dual
diagnosis sufferers.

Cheema admits the existing treatment system for dual diagnosis patients is
not co-ordinated and that people are "falling through the cracks," but says
groups shouldn't expect any new funding.

Cheema argues recent streamlining of the province's health regions into
five super-regions, plus the recent transfer of addiction services from the
Ministry of Children and Family Services to the Ministry of Health
Services, will help solve the problem by better co-ordinating addiction and
mental health services.

"We've taken the first steps but the issue is complex. I'm working closely
with health services to make sure there's a co-ordination of services and
hopefully we'll get results," Cheema said.

Louis is unconvinced, claiming the Ministry of Health Services is one of
several ministries-including social services, housing, the Attorney
General's Ministry and education-that deal with dual diagnosis sufferers
and need to be included in any co-ordination efforts.

"Collapsing 52 healths regions into five won't improve services. A
schizophrenic sees a doctor for one hour a month, but for the other 29 days
and 23 hours they are having to deal with things like food and rent and
transport and trying to get some training," said Louis, who has not heard
back from Cheema on his request that a multi-ministry group be formed.

For Olga Turok, her greatest concern is that a focus on dual diagnosis
patients will come too late for Leo. "He calls every few days and I think
he stays in the Downtown Eastside or with friends somewhere near UBC.
Sometimes, he seems to be in control and it looks promising, but every time
there is disappointment. It's played a lot on my nerves and I've had my own
depression and sleeping problems but it's my priority. Something has to change."